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CMS issues third Critical Care Comparative Billing Reports

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CMS issues third Critical Care E/M Comparative Billing Reports 

The Centers for Medicare and Medicaid Services will release the third letter in a series of Special Edition Comparative Billing Report letters on Part B claims for critical care evaluation and management services in late November.

So today basically, we are going to discuss the third critical care E/M Comparative Billing Report issued by CMS and what does means by Comparative Billing Report. So here we go!

Medicare and Medicaid Services developed the Comparative Billing Report program as a training tool for providers to improve proper billing and prescription procedures and support healthcare professionals’ internal compliance initiatives. Comparative Billing Reports assess a provider’s billing and prescription trends to those of his or her peers within a provider network that may be susceptible to erroneous Medicare Part B payments. Each Comparative Billing Report (CBR) is unique to a specific provider, is only distributed to that provider, and is not available to the public.

Comparative-Billing-Report

Comparative Billing Reports to Focus on Evaluation and Management Services

Latest communications from the Centers for Medicare and Medicaid Services and the Office of the Inspector General for the Department of Health and Human Services indicate that CMS and its consultants plan to concentrate on and stringently investigate healthcare professionals’ trends of implementation associated with Evaluation and Management (E/M) codes. 

All providers who bill E/M codes must make efforts as the portion of their compliance management program to ensure that the codes billed accurately reflect the service quality provided, that they have proper documents in their health records to endorse the stages of codes billed, and also that the service level was medically appropriate.

Since 2010, the Centers for Medicare and Medicaid Services has partnered with SafeGuard Services to provide Comparative Billing Reports (CBRs) to providers for services that pose a significant risk to the Medicare and Medicaid programs. As a result, centers for Medicare and Medicaid Services designated E/M Services as a Comparative Billing Reports issue and stated that the reports would be available starting June 4, 2012. 

Comparative Billing Reports include data-driven tables and graphs that compare a provider’s billing and payment trends to their peers on state and national levels. Comparative Billing Reports will be sent to a maximum of 5,000 doctors. Those who do should carefully examine the information to see if it labels them as an anomaly in comparison to their colleagues.

However, the Centers for Medicare and Medicaid Services have emphasized that Comparative Billing Reports are supposed to be a conformance tool rather than a punishment or indicator of deception. The emphasis on E/M Services for Comparative Billing Reports corresponds with the issuance of an Office of the Inspector General study titled Coding Trends of Medicare Evaluation and Management Services.

The Office of the Inspector General investigation evaluated coding patterns in E/M services from 2001 to 2010, concluding that costs for these services climbed 43 percent between these years. Although the Office of the Inspector General study only looked at trends and not the adequacy of underlying documents, it was supposed to be the first of numerous reviews that will look at this issue. The Office of the Inspector General advised the Centers for Medicare and Medicaid Services to create Comparative Billing Reports for E/M Services and to utilize these reports to identify and monitor providers who routinely bill greater levels of E/M codes in this report.

The Office of the Inspector General report also advised Centers for Medicare and Medicaid Services to undertake additional evaluations of physicians with significantly greater level E/M codes to verify that medical claims are acceptable and additional payments are recovered. Unfortunately, many professionals assume that higher-level codes may be justified only based on the patient’s illness’s complexity. Therefore, it is critical to note that the documents in the health record must also verify the level of code selected.

In contrast, even when a claim is well-documented and contains extensive proof, the ultimate payment criteria remain the treatment’s medical necessity. The rising use of electronic medical records makes the writing of the history and examination quicker and more through templates. Therefore, it has become a more significant issue. Regardless of the proof, it is not permissible to bill a greater level of E/M service when a lesser level of service is necessary.

Another typical major hurdle for many providers is regularly selecting the same level code. Several practitioners choose lower-level codes than are needed by the patient’s condition because they are terrified of an audit, do not have time to capture all of the material required for a higher-level code, or do not comprehend the E/M selection process. 

Centers for Medicare and Medicaid Services prefer to see a variety of E/M codes that resembles a bell-shaped curve. Thus repeatedly selecting a lower code than required can lead a provider to be an exception and increase audit risk. Towards that end, all superbills, routers, or EMR templates must include all levels – not only the higher levels or anticipated to be utilized due to the patient demographic.

What do Comparative Billing Reports mean?

The Comparative Billing Report makes it very apparent that it is solely for educational reasons, demonstrating how the receiver compares to peers at both the state and national levels in terms of employing 99211-99215 and modifier 25. The purpose of these reports is to give a tool that helps providers further understand relevant Medicare billing laws. And also, it helps to improve the level of care they deliver to their medical patients. It is not intended to imply that the physician is charging inappropriately.

As part of the existing Comparative Billing Reports, eGlobalTech computes an average allowable minute per visit by multiplying the regular times for 99211-99215 (as written in CPT) by the numerous times that each of these codes was billed and then reducing by the total number of 99211-99215 billed. It is an approximation that aims to depict the practitioner’s position in a bell curve for 99211-99215 usage with a single number. Although neither Medicare nor its vendor knows how much time the practitioner spends on a specific visit, there is no indication in the Comparative Billing Report that the practitioner could not have performed the number of services billed depending on this estimated duration.

Peer Code Comparison of Comparative Billing Reports

The report contains information on the following E/M families:

  • 92002 and 92004
  • 99201–99205
  • 99212–99215 with provider specialties other than 18 or 41
  • 92012–92014 with no provider specialty other than 18 or 41
  • 92012, 92014, and 99212–99215 with specialty codes 18 or 41
  • 99221–99223
  • 99231–99233
  • 99238–99239
  • 99281–99285
  • 99304–99306
  • 99307–99310

The following variables are included in the attached files:

  • Specialty Code: The provider’s specialty occurs in the Part B National Summary Data file.
  • Description of the Provider’s Speciality: A description of the provider’s specialty.
  • A procedure code is a code that is used to describe a service provided to a beneficiary.
  • MAC Services: MAC permitted services specified in the Part B National Summary Data file.
  • Specialization Percentage of Use in Each Region: Total authorized services for the selected procedure code and specialty for the contractor represented as a percentage divided by total allowed services for the E/M code family and thing for the contractor. The computation is based on the contractor’s permitted services.

Legal services for the selected procedure code and specialty nationwide divided by the total number allowed services for the E/M code family (and any related modifiers) and specialization nationally expressed as a percentage. The computation is based on the legal services for the nation.

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Nora R. Tripp
I am a self-motivated medical billing and coding professional with over 15 years of experience in health operations management, billing, and coding. Expertise in ICD-9 and ICD-10 coding, as well as CPT and HCPCS coding. Expertise in evaluating and validating patient information, diagnoses, and billing data. I demonstrated leadership abilities that allow for the processing of large amounts of patient information in order to satisfy revenue generation targets.

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